Healthcare Provider Details

I. General information

NPI: 1861116873
Provider Name (Legal Business Name): KRISTY BAKER PSYD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22344 SW MAIN ST
SHERWOOD OR
97140-9416
US

IV. Provider business mailing address

22344 SW MAIN ST
SHERWOOD OR
97140-9416
US

V. Phone/Fax

Practice location:
  • Phone: 503-625-2768
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: KRISTY BAKER
Title or Position: OWNER
Credential:
Phone: 503-625-2768